Do No Harm

I called my son’s name once more, hoping my shaky voice didn’t expose the panic rising in my chest, stealing my breath away. My heart felt like a tambourine banging against my ribs, futile alarm bells that no one heard but me. I didn’t want to scare my son but I also didn’t want to alert a potential predator lurking in the store. I didn’t want to broadcast that my young son was away from my protective arms, easy prey to be snatched up or lured away.

I ran up the aisle of washers and driers, nearly colliding with my husband as he rounded the corner. “Nothing?” I whispered, a desperate plea for him to contradict the obvious – he was clearly alone.  He shook his head and kept moving, his sharp eyes darting up and down, side to side. He was scared, too.

I stopped moving, weighing my options. Should I alert the store manager so they could close down all possible escape routes? Should I call 911? Should I give up the pretense of calm that I hoped would convince me that nothing terrible had happened, and scream?

“I got him!” Paul yelled.

I let out my breath and ran in the direction of his voice. My son looked up at me, oblivious that I thought my world had ended. I reached down and pulled him toward me, unable to hold back my tears any longer. Still, I tried to hide them from him. I wanted to shield him from the fear and danger and sadness in the world. For a few fleeting moments that felt like an eternity, I was helpless to protect my son.

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What if those moments stretched into days and months?

Over 3 months ago the United States began systematically separating parents and children seeking asylum. Thankfully, this inhumane policy was soon reversed after Americans expressed their outrage. Yet the July 25th deadline for reunification came and went with 559 children still not reunited with their parents. 386 of these children belonged to parents who have already been deported (without their children!) and 26 had no contact information. How this can even happen when my cell phone can tell me exactly where I parked my car without my even requesting it?

I remember so clearly the terror of my brief separation from my son in the busy department store even though it was nearly two decades ago. I can only begin to imagine what it might be like for a mother to have her child forcibly taken from her arms – and how much more terrifying for this to happen in a foreign country, one where I might not speak the language or know the laws.

I try to imagine the amount of desperation that would compel me to leave my country, dragging my hungry and frightened sons in tow for weeks on end. I imagine my exhausted relief when we’d finally made it to the country I hoped would take us in for asylum. Surely any humane country would have compassion for my dangerous plight with young children. Surely they’d want to help us.

But what would I do if instead of welcoming us with open arms, we were met with angry words? If the children that I’d fought so hard to protect were torn crying from my arms? If I was told (as some mothers have reported) that my children would be put up for adoption? Suddenly the terror of my situation would become real. Who would take care of my children in this country of heated anti-immigration sentiment and racial unrest? Who but their mother knew their food preferences, their allergies, their medical problems or even how they liked to be tucked into bed? Who would hold them and rock them and protect them? Could I put on a strong front and smile and wave at my children as they disappeared from my sight so that they wouldn’t become frightened by my horror?

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And these children weren’t just taken away to a room down the hall. Some were shipped across the country with no idea where they were going or what happened to their parents.  What is the message America is sending? “Give me your tired, hungry, poor, yearning to breathe free” so that we can detain and humiliate them. So we can deport them back to their impoverished, war-torn countries. Sometimes without their children (who we may have misplaced).

It’s one thing to impose a travel ban and deny entry to desperate people based solely on the country they happened to be born into. It’s another thing to detain as criminals those who’ve already arrived, risking their lives seeking asylum from violence and war. I’d argue that the refugees who make it across our borders should be hailed as heroes, not criminals. These parents have sacrificed everything to bring their children to “safety.” I hope that if my own sons were starving or threatened by violence that I’d have the courage to scoop them up and leave. I can’t even imagine the sense of urgency if I were raising daughters.

Aside from being a violation of human rights, separating children from their parents causes emotional trauma that will be devastating for years, if not a lifetime. As a mother I am heartbroken, but as a doctor I am outraged. I know the effects of toxic stress and trauma on children. Beyond even the obvious mental health risks known to be associated with toxic stress (including suicide and substance abuse) children are at increased the risk for many deadly diseases. It shortens life expectancy, not by months but by decades. We’re doing a lot more than just disrupting family units. We’re potentially destroying lives.

https://poundofpreventionblog.wordpress.com/2018/05/30/childhood-trauma-impacts-future-health/

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There is another issue that cuts to the heart of why this is so distressing to me as a doctor. Doctors commit to caring for all who seek their services, regardless of socioeconomic status, race or religion. A doctor’s office (or hospital) is one of the few places where both the working poor and the wealthy often occupy the same space in the waiting room. A hospital holds black and white, Muslim and Jew, gay and straight – sometimes in the same room. When we segregate and separate we lose the chance to face our fears about “others.” We lose the opportunity to marvel at our shared humanity.

Atul Gawande, surgeon and public-health researcher, spoke eloquently of the risk of excluding others in a commencement address at U.C.L.A. Medical School in June. He spoke about a foundational principle of medicine – that all lives are of equal worth. He admitted that while doctors don’t always live up to that principle, they are ashamed when people are denied treatment or given different treatment because of poverty, race, sex or lack of connections.

He continued:

We’ve divided the world into us versus them—an ever-shrinking population of good people against bad ones. But it’s not a dichotomy. People can be doers of good in many circumstances. And they can be doers of bad in others. It’s true of all of us. We are not sufficiently described by the best thing we have ever done, nor are we sufficiently described by the worst thing we have ever done. We are all of it.

Regarding people as having lives of equal worth means recognizing each as having a common core of humanity. Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.

We are in a dangerous moment because every kind of curiosity is under attack—scientific curiosity, journalistic curiosity, artistic curiosity, cultural curiosity. This is what happens when the abiding emotions have become anger and fear. Underneath that anger and fear are often legitimate feelings of being ignored and unheard—a sense, for many, that others don’t care what it’s like in their shoes. So why offer curiosity to anyone else?

Once we lose the desire to understand—to be surprised, to listen and bear witness—we lose our humanity. Among the most important capacities that you take with you today is your curiosity. You must guard it, for curiosity is the beginning of empathy. When others say that someone is evil or crazy, or even a hero or an angel, they are usually trying to shut off curiosity. Don’t let them. We are all capable of heroic and of evil things. No one and nothing that you encounter in your life and career will be simply heroic or evil. Virtue is a capacity. It can always be lost or gained. That potential is why all of our lives are of equal worth.

All of our lives are of equal worth.

Exclusionary policies are not new in our country, but where they were previously partially disguised (Jim Crow) they are now openly promoted by the rallying cry of a leadership calling for a wall. We often don’t even treat our own citizens well – from racial profiling (jails disproportionately filled with black youth) to banning silent protests (taking a knee) and discrediting the voices of the press (who are supposed to keep us informed) and anyone else who opposes a hateful agenda. We’ve become a nation afraid to talk to our neighbors for fear the conversation will not be civil.

Hate isn’t the answer. Exclusion isn’t the answer. We aren’t a strong country by living separate lives in isolation. We’re strong when we join together and help one another and stand up for and speak out for what is right.

As a doctor, I made a promise to care for any person who came through my office door. This wasn’t a difficult vow for me to make because I do believe that all lives are of equal worth. I also pledged to do no harm, a sentiment I think everyone should embrace.  This includes preventing harm when possible. It also includes not knowingly standing by when others do harm.

As a family doctor in rural New York, I feel helpless to protect the mental or physical health of families torn apart while seeking asylum in my country, I do, however, understand the devastating health risks of their prolonged trauma. The least I can do is give these families my voice in opposition.
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Childhood Trauma Impacts Future Health

Oliver squirmed in his seat. He looked around the room, then back at his feet. He glanced toward the door as if planning his escape. His eyes looked everywhere but at me.

“He needs medication!” his mother repeated. “He’s always fighting with his brothers. He can’t sit still. He never listens.” She knew the symptoms of ADHD, she explained to me, because she had also been diagnosed with the condition and both of Oliver’s brothers were on medication for it.

I hadn’t seen Oliver since his little sister was born 3 years earlier, so I wasn’t sure how he behaved outside of my exam room. Although he fidgeted a little, he was not climbing over the exam table or opening and closing the drawers and pulling things out of the trashcan. He was not trying to make a balloon out of rubber gloves or pumping up the blood pressure cuffs like many of my hyperactive patients. In fact, he was sitting quieter than my own energetic sons had sat at the doctor’s office.

“I try not to medicate 5 year olds if there are other options,” I said. “And when medication is necessary, I need to be certain of the diagnosis.”

“But he’s making us crazy! I called the office last week to get my antidepressant medicine increased. I even started smoking again!” she said, implying the fault lay with Oliver.

I took a deep breath. Oliver’s mother looked exhausted. I knew she was doing the best she could with a challenging home life. She’d recently found the courage to leave Oliver’s abusive father this year when he was sent to jail on drug charges. A pill would seem like the easiest solution for her.

But I just wasn’t convinced medicine was the answer for Oliver. I tried to get his mother to understand my reasons for not sending him home with a prescription. I explained how ADHD is diagnosed and that I required information from both his home and school to determine if Oliver met the criteria (criteria that was truthfully only validated for ages 6-28). I explained to her that the forms I’d have both her and his teacher complete helped screen for emotional, behavioral, and academic disorders.

I suggested referring Oliver for further testing to rule out a learning disability or other mental health condition (like anxiety) that had symptoms similar to those seen in ADHD. Because of his young age, if he truly needed medication to be successful in school and to be able to interact appropriately with his peers, I would want him evaluated by a psychiatrist first.

My words fell on deaf ears. “So, you aren’t going to give me a prescription?” she asked, narrowing her eyes at me and crossing her arms over her chest. “I don’t know why I wasted my time,” she added under her breath.

“Let’s make an appointment in 4 weeks,” I said. This would give her and Oliver’s teacher time to fill out the questionnaire. “We can go over everything then,” I said.

Oliver’s mom finished her form before she even left my office. She gave Oliver the highest score (“very much”) on almost every question, raising concern about the validity. While he certainly could be quarrelsome at home, could he really be cruel? If he had stomach aches, or other aches and pains or regularly complained of vomiting or nausea, wouldn’t she have brought him into the office in the last 3 years? Could the quiet boy sitting in front of me avoiding my eyes really be a bully? I didn’t think so.

A week later I received a completed form from his teacher that revealed an entirely different child than the one described by Oliver’s own mother. His teacher marked “just a little” next to overly sensitive to criticism and daydreams, but the rest of the questions were marked “not at all.” She wrote on the bottom “Oliver is a delightful child. He sometimes lets his excitement get in the way of taking turns, but is easily redirected.”

Oliver’s mother called me that day demanding I put him on medication. I asked her to keep Oliver’s upcoming appointment with me so that we could go over the returned forms from both home and school. Clearly something was going on, but it wasn’t ADHD.

“He’ll have to repeat his grade if you don’t do something!” she shouted and hung up.

Oliver and his mother didn’t show up for his follow up appointment. I reached out to his mother and offered to send Oliver to a specialist for a second opinion. She declined.

I never saw Oliver again. Maybe his mother took him to another provider hoping for a different outcome? I know she was frustrated, desperately wanting a quick fix. She’d convinced herself that he had a condition that she herself had been diagnosed with. But how much of his acting out at home was environmental? What was the balance between nature versus nurture?

I hadn’t thought about Oliver for a long time. Recently, though, I attended a day conference on Adverse Childhood Events (ACE) and the effect of childhood trauma on development and health. As I listened to Dr. Nadine Burke Harris speak I realized that she was providing me the missing piece in Oliver’s story. As she spoke, my chest became heavy with the familiar weight of regret.  Why had I let Oliver slip away from my care without more of a fight?

Dr. Burke Harris shared with the audience the results of a landmark study conducted by Kaiser Permanente and the Centers for Disease Control involving over 17,000 patient volunteers between 1995 and 1997. The results of this research finally proved what most practitioners intuitively knew for years – traumatic childhoods produce unhealthy adults.

Researchers asked their subjects to answer 10 simple questions related to abuse, neglect and household dysfunction, scoring 1 point for each positive response. The results (their “ACE score”) were then correlated with health problems they experienced over their lives.

Dr. Burke Harris’ voice faded away as I looked at the ACE questionnaire and tried to estimate Oliver’s score based on the risk factors I knew he had. He lived in a home with domestic violence, his parents had (finally) divorced, his mother had depression, his father was in jail, and his father used drugs. I couldn’t be certain about Oliver’s answer to the other questions (like whether he felt loved, whether he had enough to eat, whether he was physically or sexually abused, or whether he felt humiliated at home).

But just based on the answers I knew for certain, Oliver’s score was at least a 5. Children with a score of 5 in the first 3 years of life have an almost 80% risk of developmental delay. They also have a greater than 50% risk of learning and behavior problems (versus 3% in children who score a 0). Children with these scores are at significantly increased risk for smoking and for using drugs by the age of 14. They have a markedly increased risk of depression and suicide.

While it may seem obvious that children raised in difficult circumstances have more substance abuse and mental health problems, I was astounded by the other health risks that high ACE scores impart. High ACEs increase the risk of developing 7 out of the top 10 leading causes of death. The risk of heart disease, cancer and stroke are more than doubled. Diabetes and obesity are also increased. An ACE score of greater than 4 causes a 20 year shortening of life expectancy without intervention. 20 years!

We now know that ACEs affect the neurologic system (causing an overactive fear response, interference with learning, and an increase in high risk behaviors), the immune system (causing increased infections, inflammation, and chronic disease), and the endocrine system (causing changes in growth, menstruation, obesity and metabolism). High ACEs also effect children at an epigenetic level, actually changing the way that their DNA is read and expressed. This alters the body’s response to stress and contributes to premature cellular aging, increasing the risk of disease and cancer.

Dr. Burke Harris said that kids showing behavior problems are actually the lucky ones. The kids that are driving parents, teachers and bus drivers crazy with their outbursts, irritability and unpredictable actions are actually the lucky ones! These are the kids that grab our attention. These are the ones brought into my office by overwhelmed parents, like Oliver. The withdrawn and quiet child often goes unnoticed or labeled as shy.

Adverse childhood events cause stress, but not all stress is bad. Stress motivates us to perform better so we can reach our highest potential. The body’s response to stressors (fight, flight or freeze) is also necessary for survival, protecting us from potentially harmful situations. It is the stress response that impels us to action if we come across a bear in the woods, before we even have a chance to think about how to react.

But recurrent, unremitting stress and activation of the stress response is not protective. Stress that is chronic and persistent (as seen in people with high ACEs) combined with a lack of a supportive caregiver is toxic stress. Far from being beneficial, toxic stress changes the structure and function of the developing brain. It also leads to a decrease in the pleasure response. Chronically stressed people require higher amounts of stimulation to get the same effect, leading to substance abuse and risky behaviors.

Over 2/3 of the United States population has an ACE score of 1. 1 in every 8 have a score of 4 or more. The impact that high ACEs have on (expensive) future health problems warrants labeling this a public health crisis. Money spent in prevention (currently just 5% of all health care spending) and early intervention will ultimately be much lower than the costly health risks associated with higher ACEs.

If your child has a high ACE score, you’re not alone. Roughly half of US children are affected.

The good news is that treatment is simple, at least in theory: decrease the dose of adversity and increase the parent’s ability to buffer stress. Research shows that parents can be the most powerful influence to combat toxic stress. It only takes one safe, stable, and nurturing relationship.

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Adverse experiences don’t define who we are. Trauma-informed doctors change the question from “What’s wrong with you?” to “What happened to you?” acknowledging that circumstances beyond our patients’ control have a crucial impact on their health.

If you were lucky to be born into a stable and loving environment and believe that none of this applies to you, you are mistaken. Everyone is impacted by ACEs, if not directly then through the people you work and play with. Once we understand the enormous prevalence as well as the potential negative outcomes in children with toxic stress, we understand the need for trauma-sensitive training in healthcare and in educational systems (so that kids like Oliver are recognized and can get help) as well as law enforcement (who frequently respond to people who may not have received the help they needed as kids).

I know why doctors are resistant to ask difficult questions. Doctors want to fix things. When we feel powerless to help, we (secretly) would rather not know because there’s no turning away from the truth once it is in the open. And every doctor knows that getting their patients needed mental health care is often a challenge in America.

“That’s why I haven’t yet started screening my patients,” I confided to a colleague sitting next to me, who happened to be a trauma therapist. “What do I do when my patient scores a 5?” I asked, thinking of Oliver. “What happens when I know they need help and I don’t know how to get it for them?”

“Send them to me,” she whispered back.

And with that, I had no excuse not to screen my pediatric patients. I looked around the room at the hundreds of mental health providers, teachers, and law enforcement attending this conference with me and realized that I’m not alone in this battle. My job is not to fix everything. It’s to identify the kids that really need help before they really need it. I can no longer justify waiting for kids to fall apart (and eventually need even more expensive care for their future health problems), especially because negative behaviors often don’t appear until the 4th grade (possibly like Oliver).

Dr. Burke Harris also recommended addressing 6 key areas with patients experiencing toxic stress. And (best of all) these 6 things are not unfamiliar territory – I address them regularly with my patients. They include: Sleep, Exercise, Nutrition, Mindfulness, Mental Health, and Healthy relationships.

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I got this.

If you don’t recognize you might have ended up just like the most troubled young person you know, leave this work as your lack of empathy renders you useless… (B Morse).

For more information, check out stress-health.org (for parents and caregivers), centerforyouthwellness.org (for advocates), NPPCaces.org (for health care providers).

 

Loneliness

“I love you, Dr. Baker!” my elderly patient said reaching her hand out to me as she was wheeled from the exam room. I briefly stopped the EMT rolling her stretcher and took her frail hand into mine. She gripped it tightly and looked up at me with fearful eyes. I bent over and kissed her on the cheek and told her she would be alright. Her pale face brightened for a moment and she loosened her grip and let go.

I imagine that kissing patients is something that would’ve been frowned on in my training. It isn’t something I do every day and certainly not to all my patients. For many people, though, healing has more to do with the spiritual than with the scientific. People need connection. They want to be touched. And so, when it seems appropriate, I do. I hold their hands. I hug them. And, occasionally, I kiss them (mostly the elderly). Touch makes them feel like they aren’t alone.

I’m very aware that the reason I can display this kind of affection is because I’m a woman. Women are nurturers. It’s acceptable for us to be tender and to show emotions. I’ve been grateful for the open intimacy of women since I was a giggling teenager holding hands and gossiping with my girlfriends. Women bond together easily and aren’t afraid of physically demonstrating their love. It’s one of the many reasons I’m thankful to be a woman and probably the main reason I prefer female doctors (though I admit I’m biased).

The act of purposefully reaching out to touch another person connects us physically and emotionally. Touch is important in healing, from a doctor squeezing a patient’s hand to a parent giving their infant a massage. I remember my surprise at learning during my evidence-based medical education that there were actually medical benefits to infant massage. Studies show that massage stimulates growth in preterm babies, which is essential for survival in the NICU. Touch makes babies grow! When my third son Orion was born I signed up for an infant massage class at my local hospital, but not for the health benefits. I just loved to roll his chubby folds in my hands. I wanted to hone my skills.

We attended class faithfully. I was a serious student. Orion had no choice. Not that he suffered at all. Like most babies, he loved massage. At home I put him down on a sheepskin rug in front of the wood stove between my outstretched legs. The soft swishing sound as I rubbed almond oil into my hands signaled to him what was coming. He kicked his legs in the air and flailed his arms in joyful anticipation.

My face hovered inches above his as I took his pudgy feet and made small circles with my thumbs along the skin that would one day become his footprint. There was nothing to do, no place to go, nowhere to look but into his eyes. How could any parent massaging the soft chunky skin of a smiling baby not fall in love again and again?

A pediatrician mentor told me once that becoming a new parent was one of the only times in a young person’s life when a doctor’s advice could have a life-changing impact. Expecting parents wanted to do what was best for their baby and were often willing to make radical changes in their own health, even quitting smoking or using drugs, for the benefit of their unborn child. As a mother I experienced firsthand the impact of infant massage on bonding. After all, it’s easy to fall in love with a child smiling up at you while your hands and hearts interact. It’s hard to hurt or neglect someone you adore. I took my mentor’s counsel to heart and signed myself up to become a certified instructor.

Like most of my learning endeavors, the real benefit wasn’t one I could give away. My training did provide me a new tool to share with my bewildered young parents and I gained a deeper appreciation of the power of touch to connect and to heal. Infant massage also gave these overwhelmed parents something more fun to do with their newborns than feeding and changing diapers. But the most amazing benefit my patients (and I) experienced was the beautiful beginning of a lifelong, loving relationship with our babies.

Infants and the elderly are the easiest to bestow affection on but they aren’t necessarily the ones that need it the most. While young women freely touch and hug their girlfriends, this isn’t as socially acceptable for adolescent boys. Touch is often avoided for fear it isn’t manly. Boys don’t often develop the same level of closeness with friends, in part out of fear of homophobic labeling and in part because they lack male role models showing this to be okay.

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My sons, cuddling

But boys need connection and affection as much as girls and the pain that results from not fulfilling this need is damaging. Social pain stimulates some of the same areas of the brain as physical pain. The two are interconnected – social pain magnifies physical pain and social companionship can help relieve it. Drugs that treat physical pain also decrease social pain, which may provide some insight into the opioid epidemic.

Young men are discouraged from seeking help because pain is viewed as weakness. And so they feel alone. They learn to express their pain and sadness as anger, which is more socially acceptable. They suffer in isolation. For some boys it’s easier to hate than to admit being hurt. It’s easier to spread the pain than to internalize it.

The pain of loneliness isn’t always limited to the person experiencing it. Social pain and loneliness in boys combined with our cultural expectations of manhood can lead to tragic violence. After 20 years of research, Professor Niobe Way concluded that it is no coincidence that the mass shootings haunting our recent memories are often committed by lonely young men at the peak age of social pressures to be masculine.

Obviously loneliness doesn’t always lead to violence. But loneliness is always bad for health. The late Professor John Cacioppo, founder of the field of social neuroscience, said “To grow to adulthood as a social species, including humans, is not to become autonomous and solitary. It is to become the one on whom others can depend. Whether we know it or not our brain and our biology have been shaped to favor this outcome.” Put simply, humans are social animals. We have an improved chance of survival in social groups.

Socially isolated people suffer from higher all-cause mortality including cancer, infection and heart disease. Professor Julianne Holt-Lunstad of Brigham Young University compares the health risks of loneliness to smoking 15 cigarettes a day. She argues that loneliness should be treated as a public health priority since the health risks exceed those of overindulging in alcohol, physical inactivity, and obesity. In other words, loneliness is a public health epidemic.

The good news: companionship is protective. Social connection not only decreases stress hormone levels but is associated with a 50% reduced risk of early death. We live longer when we are socially connected.

Loneliness isn’t the same as being alone. Loneliness is perceived social isolation. Brené Brown writes about “true belonging” as a way to combat this isolation. “Belonging is the innate human desire to be a part of something larger than us. Because this yearning is so primal we often try to acquire it by fitting in and by seeking approval, which are not only hollow substitutes for belonging but often barriers to it. Because true belonging only happens when we present our authentic, imperfect selves to the world. Our sense of belonging can never be greater than our level of self-acceptance.” The work begins with being compassionate to ourselves, despite our imperfections.

We can also set the foundation for connection in our own families. I’m blessed with three sons who probably didn’t always appreciate my smothering displays of affection. They never shrunk away from it, though, and I suspect they understood on some level that they really needed it. The first time I realized that this wasn’t the norm was while waiting for my older two sons to finish soccer practice. I was standing by my car talking to the father of another player. My oldest, a senior, spotted me and left his group of friends to kiss me on the cheek and tell me that he had to run to the locker room real quick. He was followed a minute later by my other son, a sophomore, who yelled “Momma!” and jogged over and kissed me too. I turned my attention back to the father I’d been speaking to. He looked bewildered. “How did you do that?” he asked. At first I didn’t know what he meant. “Your boys just came over and kissed you on their own!” he said. I vowed to myself to never take their affection for granted again.

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Big Brother consoling Little Brother

Even more encouraging is that it’s never too late to start. It doesn’t matter if you weren’t raised in a family that hugged and kissed openly. My husband Paul’s father lost his own father to the Nazis when he was only 4, growing up in war-torn Poland without a nurturing male role model. As a result, even though Paul knew that his father loved him deeply, they had little intimate contact growing up. Something began to change for Paul’s father when Paul became a father himself. Paul has always been very affectionate with his boys. It may be that Paul’s behavior with his sons became the model that his father never had. Now Paul and his father comfortably embrace and show their love whenever they get together.

But how important is touch, really? I recently made an appointment for my oldest son (now a man) to get his first professional massage, hoping to lift his spirits. I wasn’t sure what to expect when I picked him up afterward. Maybe it was awkward and unpleasant? As he climbed into my car, I asked him about his experience. He smiled at me and said “I felt cherished.”

Formal massage isn’t necessary to feel this emotion. We also feel cherished when we are seen, when we are heard, and when we are touched. A hug is often enough. A smile can be, too. We can never know the suffering of the people whose paths we cross. If we treat everyone with the love and kindness that we naturally display to our beloved, they will feel cherished. No formal education is necessary to reach out to lonely person. No degree is required.

While this level of intimacy is frequently absent in the medical office today, I believe that detachment during patient care is not only unnecessary but also potentially damaging. Professor Saki Santorelli of UMASS writes eloquently about the physician’s role in connecting with patients in his book Heal Thy Self: Lessons on Mindfulness in Medicine. Santorelli writes “Our privilege and responsibility as servants of the healing arts is to create an environment, provide a method, and inspire people to touch what we, beyond any evidence to the contrary, know is who they really are because we have touched this within ourselves.”

Santorelli continues “Our willingness to begin with ourselves, embracing the fullness of our lives, whatever the landscape, is where practice begins. When such a practice becomes the core of the healing relationship, we encourage the same willingness in others. This is necessary if healing is to occur.”

Don’t just look, but see. Don’t just listen, but hear. Don’t just touch, but feel. Give your full attention. The life you change could be your own.

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For the Love of Nurses

I’ve always loved nurses. My mother, one of the women I admire most in the world, is one. My sister is one, too. As a doctor, I’m lucky to work with nurses every day. Unfortunately, though, in the world of electronic records and quality measurements my nurse and I work apart more than we work together.

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My Mother at Boot Camp to Become a Flight Nurse 

Doctors and nurses make a great team, especially when left alone to simply care for our patients. This rarely happens today. Instead of focusing their full attention on patients, the healthcare team is routinely diverted to more mundane tasks like data entry, paper signing and insurance appeals. They’re still on the same team, only the game has changed. Instead of working cooperatively together, they often work separately. The team is not happy with their new role, but the one who really suffers is the patient.
I didn’t realize when I first became a doctor how much I would depend on nurses, but it didn’t take long to find out. My first rotation in residency was the terrifying Intensive Care Unit (ICU). I had no idea what to expect. I wore my pressed new lab coat with my name badge identifying me as “Doctor,” but was oblivious about my role, having never spent any time in an American hospital. The white coat I’d waited so long to wear didn’t magically instill in me the confidence I had hoped it would, like putting on a superhero cape.
In Polish hospitals where I began my training the doctor’s role was seemingly endless. Doctors did everything from taking blood pressures and temperatures to physically tracking down results (and wandering patients). They delivered medications. They drew blood. They were an integral part of every facet of patient care.
It was clear from my first day in residency that things were very different in American hospitals. A sympathetic nurse simplified my job for me, “You write orders in the chart and we follow them.” So, all I had to do was write down what I wanted and it would be done? The job was suddenly both simpler and less noble than that of the Polish doctor. What I’d soon realize was that these hospital employees who awaited my orders would be the very people I’d rely on most in the future to guide me, keep me sane and keep our patients safe.
Nurses were indispensable.
Every morning before ICU rounds my colleagues and I spoke with the evening nurses to find out how our patients had fared in the night under the half-asleep watch of the exhausted on-call resident. I discovered quickly that when I was the on-call ICU resident I should expect no sleep. Alarms beeped all night. The very act of clipping my pager to my lab coat caused my heart to pound. On the rare occasion that I closed my eyes for a few minutes, compassionate nurses gently shook me awake on behalf of patients needing immediate attention. A page from the ER meant an admission, a process that took at least an hour to complete. And when my work was done, the nurses took over.
I thought I’d be ahead of my childless peers, used to frequent nighttime awakenings from a hungry, crying infant. Unfortunately, this sleep deprivation was nothing like nursing a baby in the night. Not only were the awakenings unpredictable and frequent, but they also they required a different level of consciousness. A page from an observant nurse watching over my very sick patients required an instantaneous transformation to full daytime mental capacity. Lives depended on it. Sometimes I just stayed awake all night in anticipation of imminent disturbances from dying patients and sometimes because it was better to stay awake than be jarred awake forcibly.
In those early hours when the hospital halls were quiet and empty, I marveled at the dedication and knowledge of the nurses. When a patient took a turn for the worse and the resident ran out wide-eyed and terrified, the composed nurse made helpful suggestions without being asked. “Would you like me to draw up a little morphine, maybe just a milligram to start?” Or, slightly more urgently, “I’ll get the crash cart and call the senior resident, just in case.” They knew medicine, but more importantly they intimately knew their patients (and their family members).
When I was almost 5 months pregnant with my second son, I rotated through the Neonatal Intensive Care Unit (NICU). Some of the babies in the incubators were younger than the one growing inside me. I cradled my belly in my hands as I watched over these scrawny, hairless infants attached to tubes and wires. I looked carefully at their charts, taking note of the gestational age of all of the premature babies, which provided me an amazing glimpse of the development of my own unborn son.
I tried to comfort pale, wide-eyed mothers as they sang to their babies through the plastic incubators. I watched as fathers stroked them with gloved hands poked into a small opening in the side wall. Frequently, alarms blared and stricken parents were pushed aside by a team of providers rushing to save their baby. I wondered if I could ever be as strong as these brave parents. I wondered if I would ever be as knowledgeable as their doting nurses.
NICU babies’ lives were dependent on bed alarms, frightened residents, dedicated doctors and (probably most importantly) attentive nurses. There was no room for error, exhaustion or a bad day for any member of the team – a scary thought for a pregnant resident. Fortunately, the NICU nurses were an amazing source of expertise and strength. They buzzed around the unit averting disasters while calmly directing gaping residents how to help. They provided reassurance to terrified parents and consoled devastated ones.
When babies graduated from “critical condition” to “feeders and growers,” the nurses rejoiced as they deftly slipped their charges out of incubators and gently placed them into the long-waiting arms of mothers. When a baby was ready to be discharged home, it was the NICU nurse who taught the parents how to care for their unique needs and when to seek help.
Sadly, practicing medicine has changed a lot since my residency. Instead of working side by side with my nurse in the care of our patients, we often work independently on separate administrative tasks at our computers. Still, my admiration for nurses has grown since my early years as a terrified resident. I’ve worn the badge of doctor for more than two decades now yet I have no illusions about the critical importance of my nurse, even though our jobs are different. She stands in front of me like Wonder Woman, deflecting solicitors, angry patients and insurance company probes. She’s the first to offer comfort to my suffering patient and tells me when they need a little extra attention. She reminds me before I enter the exam room if my patient has recently lost a spouse or had a new grandchild.
My nurse is like a pressure-relief valve. She takes care of much of the bureaucratic busywork sifting through my piles of papers, filling out the parts she can and organizing them so I can take have a little more time with my patients. She knows which forms to complete out to allow my patients to stay on their diabetic medications when their insurance formulary changes. She stands by the fax machine, copies the paperwork, and triages the phone calls. She calls the pharmacist to confirm what medications my patients are taking when they forget their list. She calls the hospital to get discharge summaries and the specialist’s office to request test results. She collects the urine, swabs throats and nasal passages, bandages wounds, records the vitals and reviews the allergies. She cleans up the vomit, disinfects the room and brings my shivering patient an extra blanket. She’s the bad guy who gives the shots I order.
So, what does the doctor do? I wish I could report that while the nurse was working behind the scenes the doctor was in the room caring for the patient. Sometimes I am, but much of my time is devoted to activities unrelated to their direct care. I sign hundreds of papers each week, some in ink and some electronically. The volume is overwhelming. Sometimes the signature is on emergency room visits, test results performed elsewhere or reports from the specialist office. On these papers my signature just means “Yes, I saw this, please file in the chart.” I skim these papers (though I know I should read them thoroughly) because there isn’t enough time in the day for me to meticulously read them even if I wasn’t seeing patients. Other times I sign for medical equipment for a patient (like a wheelchair, CPAP machine or crutches) or for tests to be performed (like a chest x-ray, hearing evaluation or bone density).
But doctors don’t just sign their own papers, they co-sign written orders from nurse practitioners (who are able to prescribe drugs, remove skin lesions and do pretty much everything the doctor can do except apparently sign orders). This even includes orders from visiting nurses (for things that nurse practitioners actually did themselves when they worked as nurses) – things they are likely much more qualified to sign for than doctors.
The worse offenders of needless signature-seeking, though, are adult homes. Once a week when I see patients in an adult home I find a pile of notifications waiting for my signature. “Doctor aware of 3 pound weight loss over 6 months.” Or. “Doctor notified patient slid out of chair, no injuries.” And, “Doctor aware patient seen by podiatry and had nails cut.” Really? Yes, really.
I also fill hundreds of prescriptions every week. Nurses send them to me electronically with the dosage, amount to be dispensed and the refills. I click the button that sends them to the pharmacy. I don’t have time to verify that every detail on every prescription is correct. I look at the patient’s name (Do I know this patient?) and the drug (Does it require blood work and if so when was it last done?) and the dosage (Does it look like a reasonable dose?) and the amount of refills (Have they been in the office recently? If not I ask my nurse to call them for an appointment). If something doesn’t seem right, I open the chart and check myself. I can’t do this for every prescription. No doctor could. There simply isn’t enough time in the day to double check every chart for every medication that every patient takes to confirm that the information is accurate. I must trust that the prescriptions sent by my nurses are accurate and hope that the pharmacist will call if something isn’t right. Ultimately, though, I’m responsible.
Universal health care would likely eliminate much of this unnecessary paperwork, freeing up the healthcare team to do what they do best – taking care of their patients. Most doctors I know would much rather spend less time on the computer and more time talking to and caring for their patients. Doctors want to jump off the administrative hamster wheel where they work hard to get nowhere.

But they would still be running in place if it weren’t for their nurses.

A distressed friend called me recently. Her child was in a local hospital and she worried about whether it was the right place for her. “Her nurse is wonderful, though” she confided.
“A good nurse is actually the most important thing,” I told her. “But don’t tell her doctor I said that.”

Public Health Notice: Guns Actually Do Kill People

I tried not to let my boys play with toy guns when they were little. I soon discovered, though, that in a young boy’s imagination everything became a gun – a stick, a rolled up newspaper, a pointer finger. Defeated, I slackened my efforts. I still didn’t buy them toy guns, but I stopped reprimanding them for creating their own (although I couldn’t quite hold back from telling them that they were shooting “kisses”).

I was stung when a young mother ushered her son away from my sweet and sensitive little boy at the playground while he quietly played on the wood chips with his beloved green army men. “We do not play violent games!” she whispered with urgency, loud enough for us to hear. She glared at me as she yanked him away from us. My son looked up at me apologetically. I shrugged my shoulders and smiled what I hoped was a reassuring smile, but I shared in his hurt. I was far from pro-gun but even on the playground over a dozen years ago our country was divided.

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Buddha and Green Army Men doing Yoga Poses

As they got older, I kept my boys away from violent video games as long as I could, gently guiding them toward more creative endeavors. We didn’t get any TV stations so they only watched the videotapes we brought home. Violence didn’t enter our home with the evening news. It still came, though.

I remember my horror when I overheard my kindergartener (who was running in the grass “flying” a little toy airplane) say “Crash! Boom! Twin towers fall!” After much internal debate I had decided not to tell him about 9/11.  I thought I was doing my job as a parent, shielding him from the scary things in the world. I couldn’t protect his innocence when he was at school, though, even at his tender age. At least I didn’t have to worry about school shootings back then.

But today (despite still having no television stations) there is no escaping the violence. It flashes on the computer and cellphone. My watch vibrates in alarm with each horrific headline.

In truth, I’m not entirely anti-gun either. I live in upstate New York where some of our local schools close for the first day of hunting season. My own little dirt road probably boasts dozens of guns, some in my own home. I’ve shot skeet (poorly) and aimed hunting rifles at targets in my yard. It’s loud and jolting and not really my idea of fun. I’d rather dangle my feet in the stream and watch the frogs.

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Attempting to Use a Crossbow

Sometimes my neighbors hunt with old-fashioned muzzle loaders and sometimes with compound bows. It’s part of the challenge. They track their prey and bring it home for dinner. They aren’t hunting with semi-automatic weapons or handguns.

I’m a family doctor in a rural town. Many of my patients are avid gun enthusiasts and some are surely active members of the NRA. Some of my patients are ardent pacifists too. Most probably fall somewhere in the middle – they own guns for hunting or encourage their neighbors to hunt their property to cut back on the deer population that thrive on their lush gardens.

Because I’m a doctor, though I can’t ignore the health risks posed by guns. Guns (by their very nature designed to emit projectiles at high velocity) are dangerous. So are motor vehicles driven erratically or at high speeds or by people not licensed to drive them. This doesn’t mean guns should be banned but (like cars) there should be stringent rules to ensure their safe use by qualified people. 16 year old novice drivers should wear seatbelts and obey the speed limit. They shouldn’t drive motorcycles 100 miles an hour without a helmet.

They also shouldn’t have access to high power weapons that fire as fast as they can pull the trigger.

After the most recent school shooting in Parkland, the American Academy of Family Physicians (of which I’m a proud member) joined with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Psychiatric Association to plead (again) that America treat the epidemic of gun violence as it would any other public heath problem – identify risk factors (through extensive research of fatalities) to take steps to prevent future deaths.

Because gun violence isn’t just about mass shootings. Both suicides and unintentional injuries are on the list of the top 10 causes of death in this country. Having a gun in the home increases the risk of both suicide and homicide. The American Public Health Association and the American Medical Association label gun violence a public health problem. Yet there is minimal research on gun violence. Why?

America used to study gun violence. In 1996 the NRA lobbied Congress to pass an amendment to prevent the Centers for Disease Control (CDC) from using money for researching gun fatalities. To be clear, the CDCs purpose is to study causes of death to help prevent future ones. While they are best known for studying diseases, they also study car crashes, drownings, falls, traumatic brain injuries, suicide and more. Guns are involved in approximately half of suicides in this country and yet this amendment effectively restricts studying gun ownership as a risk factor.

The stated intent of the 1996 amendment was to forbid politically motivated research. At the same time it was passed, though, Congress lowered the CDC’s budget by the exact amount it spent on this research. In 2016 over 100 medical groups wrote a letter to Congress urging them to repeal this amendment. Even the former congressman who originally sponsored the bill requested it be reversed. In 2018 the law still stands.

The refusal to even look into gun ownership as a risk factor for death is akin to children refusing to acknowledge bed time – squeezing their eyes shut tight, plugging their ears with their fingers and shouting loudly to avoid the bad news. As if not acknowledging it might make the truth go away. That guns are dangerous. They can kill people, intentionally or not.

But guns don’t kill people. People kill people. The problem is the mentally ill.
Oh, if only it were so simple! But, the data doesn’t support this. If this were true then America would have more mental health problems than other countries (it does not). Also, countries with higher suicide rates (and therefore presumably more mental illness) would have more mass shootings (they do not). Clearly anyone who shoots innocent people is not well, but a crazy person with a knife or golf club can not inflict the same damage.

Nope. It’s about access to guns. Around 40% of Americans claim to live in a household where there is a gun. We make up less than 5% of the world’s population and boast 42% of the world’s guns. And, surprise! The United States has the highest rate of murder by firearm in the developed world.

It would appear that the guns themselves are the cause of the violence.

Well, if guns are the cause of all these school shootings, we should just arm the teachers. While an attractive theory, unfortunately adding more guns is not the solution to gun violence. Police and military personnel spend an enormous amount of time training with guns and running active shooter drills. Repeatedly. Despite this, even the professionals aren’t immune to gun deaths. An FBI study of active shooter incidents from 2000-2013 showed that police who engaged the shooter had casualties of almost 47%.  Nearly half! In the highly emotional chaos of a school shooting, a police officer protecting the innocent might shoot at anyone wielding a gun (including teachers).

To assume that simple training on the basics of handling a gun will make schools safer is like believing that a few hours in the car with your teenager will make them ready to race along a freeway in rush hour. I certainly don’t want to be in that car.

The fact is that people don’t behave predictably or reliably under stress. It’s biological – the body’s reaction to danger is fight, flight or freeze. While we’d like to think that in an emergency situation we would fight (or at least run), many of us freeze. This is especially true when the danger involves people we care about (and the teachers I know care deeply about their students).

Despite 11 years of schooling and 18 years in practice, when a medical emergency happens involving my own family I freeze (and cry while my husband takes over). When my mother was choking a few years ago, I panicked. Years of training in Basic Life Support and Advanced Cardiac Life Support (with recertification every 2 years) vanished. I froze and watched her helplessly. When my son had a febrile seizure in our car, my Pediatric Advanced Life Support certification was useless. I grabbed him from his carseat and ran barefoot down the highway waving my arms frantically until someone stopped. This is not the expected behavior of a highly trained professional.

I’m sure some teachers would be able to handle a weapon in a crisis. When my husband was a teacher, he would have done just fine. Me, not so much.

After every mass shooting The Onion runs an article with the headline “‘No Way to Prevent This’ Says the Only Nation Where this Regularly Happens”. So, what can we do? For one, we could look to other countries that have successfully tackled this very problem.

In 2013, the United States had nearly 33,000 gun-related deaths compared with 13 in Japan (a country with a third of our population). Americans are 300 times more likely than the Japanese to die by a bullet. Our gun ownership is 150 times as high. The gap between these numbers suggest that owning guns is not the only cause. The other crucial factor is gun control legislation, which tends to reduce gun murders (according to a recent analysis of 130 studies from 10 countries). Ours is weak, Japan’s is strong.

In Japan, citizens who want guns must attend an all-day training class, pass a written exam and shoot with 95% or higher accuracy. They must also pass a mental health examination and have a background check including interviews of family members and friends. If they pass these rigorous tests (which must be taken again every 3 years) they are limited to purchasing shotguns or air rifles. Tighter regulations keep guns in the hands of those proven competent to use them.

In some countries, governments bought back guns from their citizens in an effort to curb gun violence.  The result?  Gun-related deaths plummeted. After a gun buy-back program in Australia, gun deaths were cut in half. In the UK, (where the government also banned handguns, semiautomatics and pump-action firearms and required shotgun owners to register their weapons) this number dropped to 50-60 gun deaths a year.

But the American people don’t want gun control legislation!
According to a recent Gallup poll, the majority of Americans are unhappy with current gun laws and policies with most in favor of stricter legislation. A more accurate statement might be that the NRA doesn’t wan’t gun control legislation as demonstrated by the approximately $3 million spent each year to influence policy (not including millions spent supporting political candidates that oppose gun control).

But what about the 2nd amendment?
At the time the Constitution was signed state militias (comprised of able-bodied white males) were conscripted in order to suppress slave and anti-tax insurrections and to fight Native Americans. These were trained and disciplined men. The phrase “the right of the people to keep and bear arms” referred to this “well-regulated militia” and likely wasn’t meant to include individual citizens.

Even if the founding fathers did believe that individuals had the right to own guns to protect themselves from an over-authoritative government, is this even applicable today? Is an individual really going to stand up to the government with a gun? I doubt any citizen (or group) would be successful challenging our modern military’s precise and expensive firepower and surveillance capabilities not to mention extensive training. Most citizens don’t hone their combat skills with the vigor of the armed forces who train to protect our country.

Parkland students who have voiced their concerns over gun control have received death threats. We should be much more concerned about their 1st amendment right to freedom of speech.

It’s simple. To live peacefully in society, there have to be rules. Many, many, many things in our country are regulated by our government including motor vehicles, fireworks, alcohol and tobacco. The regulations are generally reasonable (for example, you must be a certain age and pass a test to apply for a driver’s license and when driving you must obey safety rules like stopping for people walking in a crosswalk).

The epidemic of gun violence puts Americans at risk every day. Protecting the lives of our young people (and all citizens) must take precedence over interpretations of Constitutional rights.

What kind of gun control rules are we talking about?
Most of the proposed rules are actually pretty logical. Reasonable restrictions include rigorous background checks to prevent perpetrators of domestic violence from wielding weapons against their victims. They also include not allowing the sale of weapons to the mentally ill or to people not old enough to drink alcohol. They include waiting periods for purchasing handguns which could potentially save lives by preventing impulsive suicides.

Gun violence has become more deadly in part due to the lethality of the weapons used. The United States should ban adaptations that convert semi-automatic guns to automatic. After all, we don’t allow our citizens to carry grenades or launch missiles (or even purchase most fireworks in my state).

On February 16th, the American Academy of Family Physicians once again urged the President and Congress to take firm action against the public health epidemic of gun violence in 3 simple steps:
▪ Label gun violence as a national public health epidemic.
▪ Fund appropriate research at the CDC as part of the 2018 federal budget.
▪ Establish constitutionally appropriate restrictions on the manufacturing and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.

I applaud these sensible recommendations.

Even my gun-loving neighbor would agree to them.

 

Make America Good Again

The first thing Paul did when we moved into our home in upstate New York over 17 years ago was to take down the satellite dish from the barn roof. We had chosen a home in the woods at the end of a dirt road because we wanted to experience nature. The dish was horribly out of place. Besides, we’d already decided we didn’t want television programming in our lives anymore.

The choice was not made out of a radical opposition to television as a symbol of society’s evil, but as a personal choice about what was important to us. Television shows simply sucked away too much of our precious and limited time. We wanted to do something rather than watch something. As a reminder of our commitment Paul carved “Don’t just sit there” and “Go do something” into the cabinet doors he made to contain our TV and video player.

I grew up with a TV in every room. While we didn’t actually eat in front of a TV, there was one in the kitchen that often served as background noise while we ate. On the rare occasion I found myself alone in the house, I turned on multiple TVs for company. I felt better with the noise. As I got older, though, I found more comfort in silence.

My family hasn’t withdraw from society entirely. We have a DVD player to watch movies and (eventually) the most popular television series at our convenience (usually months or even years after the rest of America). Because of our remote location we don’t receive signals for any stations at all, not even local ones. Unwanted commercials and violence are not automatically granted access into our home. I‘ve seen very little footage from recent natural disasters, mass shootings or terrorist attacks, which suits me fine. I don’t want those images imprinted in my memory.

Of course we sometimes miss television, especially when major world events occur (like 9/11 or the 2016 elections). We can’t even stream news because of extremely limited satellite Internet. When big events happened, Paul would make rabbit ear antennas out of bent clothes hangers, tinfoil and pieces of wire with minimal success. Now that the TV is digital this no longer works. For me, living in my occasionally frustrating but mostly peaceful self-imposed bubble is a worthwhile sacrifice for the insulation it provides from the horror of the daily news.

It’s really is no big deal. I don’t even remember I’m without television stations until it comes up in conversations to the shocked disbelief of a friend (Did you see the grand finale last night?) or a patient (Can I try the drug from the commercial with the people singing on the boat?). For a short time when my sons were young I worried they might feel excluded from culturally relevant conversations because of their lack of exposure. Then one day before Christmas they visited their grandparents and we had instant confirmation that we’d made the right choice.

Paul and I picked the boys up after shopping and bundled them into the car under a barrage of shouting over each other. I want the robot that walks! I want a razor scooter! I want G.I. Joe guys! I want a Transformer Go-Bot! I want a Game Boy with Pokemon! Paul and I stared at each other in disbelief. Our sons, who could easily busy themselves with a stick outside for hours, were screaming about what they believed they now needed to make them happy. In an instant they were transformed from content children to desperately deprived ones.

I believe most Americans can relate to how they felt. When I’m at a hotel or visiting friends and family with TV I’m quickly overwhelmed with the amount of channels alone. There are so many choices that I struggle to find a single thing I want to watch. When I finally settle on a show, I worry I’m missing something even better on another channel and start flipping again. And, I want the things in the commercials – the beautiful boat, the ocean cottage and the glamorous silky black dress. This is the paradox of choice. The more we have, the more unhappy we are about what we might not have. We develop FOMO (the very fact that this is a term for Fear Of Missing Out shows how widespread this phenomena is in our society of abundance).

As a child in Poland, Paul was happy to get an orange of his very own for Christmas. Once his family immigrated to America, his father bought practical and inexpensive gifts for his children, like a pen or a book. This was the norm, so no one felt like they should have gotten more. Christmas in my middle-class American home was the opposite. It was an extravagant abundance of unaffordable gifts, a tradition I have continued (often to my own dismay) with my sons. I wanted them to feel the same magic I felt every Christmas morning. The intensity of my desire to share this with them this won out over Paul’s more reasonable Christmas day visions.

We did succeed in making Christmas magical but while I thought it was all about the presents my boys taught me it is actually about the traditions. They notice if I don’t display every ancient Christmas decoration. There’s an uproar when Paul tries to throw away a ratty old plastic ornament. Though my oldest can legally drink, he still shakes his gifts to find out which one has the lego set. He tears it open and puts it together before we even have breakfast.

The magic of the season is in the multi-course slavic Christmas Eve feast we share with Paul’s family. Paul’s mother spends the week before Christmas in the kitchen preparing traditional fish dishes, borscht with mushroom dumplings, and cakes. For the last two years my sons have helped her to make hundreds of pierogis just before the big night. We toast each other with vodka and pickled herring. We share wafers blessed in the Polish church, each person breaking a piece off and giving it to every other family member along with kind words and wishes.

The magic is in the big Christmas breakfast served on good plates with gaudy Christmas tree napkin holders, gingerbread placemats and jumping reindeer candlesticks. It’s in setting an extra place at the table so an unexpected guest might feel welcome. It’s in piling in the car afterward to drive for hours to be with their cousins.

I don’t need to look far for excess in my own life (just ask Paul, who is constantly trying to simplify). Every change of seasons I lug bins of my clothes in from the barn storage. I take the summer clothes packed tightly together out of my closet to make room for the winter ones. As I fold each unworn item and cram it into the bin I wonder why I can’t just donate most of them to Goodwill. Why am I holding on to this bright orange shirt from college? Will I really ever wear these pants that are too short? The skirt made from scratchy material? The dress that is too tight or the one that has needed a button sewn on it since last summer?

The truth is, I wear the same comfortable handful of shirts and pants every week. If anyone paid attention to my wardrobe (which I’m fairly sure they don’t) they’d think I owned very few instead of the over-abundance of neglected clothing that spills out from my closet. I rarely wear dresses (because I can’t wear sneakers with them) and yet I have a closetful of beautiful dresses. When I need to dress up, the choice is overwhelming and I choose the same comfortable one again and again.

Why is it so hard to get rid of my clothing (or my unmatched mugs and plates and pots and pans and board games not played and books I won’t read again and snow pants that no longer fit my sons and threadbare sheets and clutter that needs to be moved around every time I clean and that doesn’t add to the beauty or joy of my home)? When I die I don’t want my sons to sort through mounds of things I’ve collected in my pursuit of happiness (or at least the false assurance that I have enough). I want to be more like my sister Ally. If you tell her you like her sweater, she takes if off and gives it to you. I want to be able to give away the things I cherish but don’t need or use to someone who needs it more.

Paul and his sister traveled back to Poland when they were in college. They took a train from Warsaw to the small town where they’d lived with their parents and grandmother before immigrating to America. Paul was hungry so he rifled through his bag until he found a banana. As he set it on the small table in front of him he noticed that the old farmer and his wife sitting across from him were staring at it intently. They spoke rapidly in whispered voices to each other, stealing glances at the fruit. Finally Paul spoke to the old man in his elementary Polish. He learned that the farmer hadn’t eaten a banana since he was a child. He hadn’t eaten a banana since he was a child. He hadn’t even seen one, such were the scarcities in Poland.

Paul held out the banana to him. At first the farmer declined, shaking his head vigorously. The gift was too generous. Paul was persistent until finally the old man relented. While the farmer lovingly pealed the banana his eyes filled with tears. His wife reached over to steady his shaking hands as Paul and his sister watched in awe. The farmer smiled, his mouth full of banana, and offered Paul a sip from his thermos. Paul moved next to him and shared his vodka for the remainder of the trip.

It’s hard for me to imagine this kind of deprivation. The pure joy in farmer’s face shows how happy people can be with so little. Many war-torn and developing countries suffer far greater hardships than most Americans will ever know. To suggest to a hungry foreigner that we need to “Make America Great Again” must not only seem absurd, but like a slap in the face.

The desire for more and bigger and better is the cause of much unhappiness globally. Weaker countries scramble in a desperate attempt to hold onto what they have while bigger countries try to steal it. On a smaller scale, the beautiful pictures and posts of our friends and family on social media has an immediate effect of causing us to wonder if we have enough, if we do enough, if we are enough. We are happy for them even as FOMO creeps in.

“Make America Great Again” implies that our country is not still great. This brilliant campaign slogan appealed especially to baby boomers who grew up in the 1950s, when America was apparently a great place to live. The economy was booming. Consumer goods were abundant and affordable because wages were high and unemployment was low. America was great. Unless you were black. Or you were a woman with bigger dreams than keeping house and staying home to raise a family. Or you were (gasp) gay.

And although the 1950s did herald many advances in medicine (like the polio vaccine and pacemakers), the mortality from heart disease and cancer rose more than 50% because of rampant smoking. With the development of new lifesaving drugs also came more frequent use of addictive tranquilizers, known as “happy pills.” The mentally ill languished in understaffed and underfunded asylums while epileptics were sterilized and underwent lobotomies. Not so great.

Americans need to change their expectations. If you are lucky enough to have a steady job, food to eat and a safe place to live then this is truly something to be grateful for. The wild pursuit of more and better is exhausting. Acquisition doesn’t lead to happiness. It just leads to the desire to acquire more. When we complain about the good old days (that really weren’t all that great for many Americans) to someone whose next meal is uncertain, we sound like whiny, spoiled children. Instead of lamenting, we might explore how we can help our less fortunate brothers and sisters. We could be kinder to one another.

We don’t need to Make America Great Again, because it already is.

We need to Make America Good Again.

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Christmas 2017

Open Arms: Immigration

If you’ve tried to schedule a physical exam with your doctor recently (or worse, tried to establish care with a new doctor) you probably had to wait a while for an appointment. Sometimes months.

If you called your doctor’s office because you had a sinus infection or the flu, chances are you were told that your doctor’s schedule was already full. If you were lucky, you were offered an appointment with another provider in the office but probably you were directed to your nearest urgent care.

That there is a shortage of general practitioners in this country is unlikely surprising. You have experienced it. And, its only going to get worse.

Many more US medical school graduates become specialists than foreign-born doctors in part because specialists are paid up to 45% more than general practitioners. This doesn’t mean that doctors who choose to specialize are greedy. Studying medicine is an expensive investment (except in countries where education is free).

And the cost is not just financial. Becoming a doctor is a lifelong learning commitment to a demanding job in a hostile healthcare system. For some, the costs simply outweigh the benefits. The result is not enough native-born doctors to meet the growing demand for primary care. This gap in care is partially plugged by foreign-born doctors.

Immigrants.

Immigrants make up more than 1/4 of US physicians. They are a major part of the solution to the primary care shortage problem.

After the travel ban was instituted, American Academy of Family Physicians president John Meigs, MD wrote a passionate letter to the president. I was proud to be a member of the AAFP as I read his words. We are writing to express the importance of this nation continuing its historical tradition of welcoming immigration and the talent and energy these individuals bring to this country. The AAFP promotes and advances the work of family physicians from all religions, races, ethnicities and cultures in the United States and around the world.

Dr. Meigs’ words echoed the sentiments of many family physicians. As an organization, we are adamantly opposed to discrimination of all types, including policies that identify or isolate individuals based on their gender, religion, ethnicity, nationality or geographic location.

The conclusion of his letter could have been written about any profession. Fully engaging all talent and expertise in the healthcare community leads to better health outcomes, diversity in medicine and should be encouraged.

Diversity in medicine should be encouraged. In truth, diversity in everything should be encouraged. Immigrants like Albert Einstein (who came to America during the Nazi occupation) and former Secretary of State Madeleine Albright (who immigrated from Czechoslovakia to flee a Communist takeover) bring diversity that makes this country competitive, colorful and vibrant.  Americans love Thai food and Chinese New Year celebrations. We like to grocery shop in Little Italy and buy Guatemalan handbags and Mexican glassware.  We love diversity.

Immigrants also bring beauty to our country.  John Muir, world-famous naturalist and the “Father of Our National Park System,” was an immigrant from Scotland.

That’s correct. An immigrant is largely responsible for the preservation of the beautiful spaces America treasures.

Unless you are a native American, your family immigrated here. Just ask any elementary student. I remember when I was a little girl that I was so proud to live in the country that took in the tired, the hungry and the poor. I believed in the magic of the melting pot.

And, if I hadn’t met and fallen in love with an immigrant, I might not have ever become a doctor.

I didn’t win a coveted spot in an American medical school when I finished college. Competition was fierce. My mentors encouraged me to try again next year. But I had no interest in finding a job in the allied health field to gain experience and make connections like many aspiring medical students. I had bigger plans for my life. I didn’t just want to be a doctor, I wanted to be a mother. I felt a sense of urgency in my career choice. It was now or never.

So, when I was accepted by a prestigious medical school in my future husband Paul’s homeland, we decided to go for it. It was one of the best decisions we ever made.

Almost 2 dozen years later, just after the travel ban was announced, Paul posted a photograph of his family on the anniversary of their immigration. He wrote: Thank you for taking us in America. I am forever faithful and grateful. One of the first comments on this post read “At least you did it legally.”

I was furious. How do you know?  I wanted to write. Perhaps it was based on the known merits of his high-achieving family. Perhaps the assumption was made because of the color of Paul’s skin. The truth is never quite so black or white, though.

Paul’s family came to America when life was becoming increasingly difficult in Communist Poland. There were strikes and long lines for food. There was a constant threat of violence and rumors that it would only get worse.

Paul’s father Piotr dreamed of a better life for his family. His mother Irena struggled with the decision. She didn’t want to leave her big Polish family and worried she might not see them again if she did. She had a sister, though, who already lived in America and offered to help. When Irena’s mother encouraged her to join her homesick sister she finally felt free to go.

A lot of pieces had to fall into place before they could make such a dream happen. First, they had to get passports out of the country, which was not easy. Many people they knew had been repeatedly refused. Piotr believes that they were able to get their passports because of family connections to The Party, issued strictly on the condition that they would return. They had to pretend to be just visiting America.

Next, they had to borrow money from impoverished family members to purchase the small apartment that they were leaving behind. Paul’s family of four shared this apartment with Piotr’s mother. There were 2 small rooms, one for the children and one for the grandmother. Paul’s parents slept on the couch. Piotr worried that his mother would be forced out of the apartment if they didn’t return.

Finally, Irena’s sister had to buy all 4 plane tickets in cash with American dollars. It was the only way to secure a spot on the chartered plane. The tickets were round trip, though they had no intention of returning.

Only 3 people knew of their intention to immigrate – Paul’s parents and Irena’s sister in America. Paul didn’t even know that they were going “to visit” America until the night before they left. It was too risky to tell the children ahead of time, too easy to destroy the carefully laid plans. Paul raced to the playground to tell his friends that he was leaving for America tomorrow. No one believed him.

I can’t imagine how his parents felt, full of hope and fear, when they boarded the plane with just a few treasured belongings. They must have been overjoyed to be given a shot at the American dream.

Paul’s family moved in with Irena’s sister and her family of 5. Eventually, they applied for political asylum. Eight year old Przemyslaw (renamed Paul) started school unable to speak a word of English. (Now he corrects mine.)

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Paul’s Family just before immigrating to America

If Paul’s family had waited much longer, they wouldn’t have been able to leave. Not long after their arrival in America, martial law was put in effect by the communist government. Military vehicles surged onto the streets and the borders were sealed. Phones were disconnected (and later tapped). Mail was censored. School was suspended while teachers were questioned about their loyalty. Those found to be sympathetic to the resistance were fired.  Media, transportation, healthcare, public services and factories were put under military management. Military courts bypassed the normal court system to imprison the opposition.

If I lived with my children in an oppressive, potentially violent society with no guarantee of our next meal, I expect that I would do whatever it took to get my children to safety.

What parent wouldn’t?

Countless parents fled such regimes to the safety of our country, many without the connections and luck that Paul’s family had. These parents now live in fear that the children they thought they had saved could be sent back to a homeland that they don’t remember. Children who were brought to America with hopeful parents looking for a better life. Children like Paul and his sister.

Like many Americans, I am outraged by the threatened deportation of DREAMers. These are the children of undocumented immigrants, many with no memories of their “home” country. Some speak only English and had no idea that they were undocumented until they applied for college.

And they weren’t just granted a free ride here. DACA (Deferred Action for Childhood Arrivals) status isn’t cheap and strict criteria must be met, including a willingness to go to college or serve in our military. Those who meet the rigorous requirements and background checks are given a 2 year deferral, a dream, to stay and earn their citizenship.

I know I am lucky to have been born in this county, yet I believe these young Americans, raised among us, are every bit as American as I am.

So does former President Obama. In speaking of the threat of deportation of DREAMers he said:

What makes us American is not a question of what we look like, or where our names come from, or the way we pray. What makes us American is our fidelity to a set of ideals – that all of us are created equal; that all of us deserve the chance to make of our lives what we will; that all of us share an obligation to stand up, speak out, and secure our most cherished values for the next generation. That’s how America has traveled this far. That’s how, if we keep at it, we will ultimately reach that more perfect union.

Universities agreed, citing DACA beneficiaries as outstanding students whose presence enriched the learning environment for all students. Dozens of CEOs (including Apple, Microsoft, Amazon, Netflix, AT&T, Wells Fargo, Facebook, and Google) also joined the protest. As it turns out, 3/4 of the top 25 Fortune 500 companies have employees who are DACA recipients.

Why are we so eager to deport these young people? Children (and grandchildren) of immigrants were likely raised with stories of deprivation. Like Paul, they were taught to appreciate their chance at the American dream and the importance of living up to the privilege of living here.  Jonas Edward Salk, who developed the polio vaccine, was the grandchild of Eastern European and Russian immigrants. Henry Judah Heimlich (of the Heimlich maneuver) was the grandchild of Hungarian and Russian Jewish immigrants. Sanjay Gupta, American neurosurgeon and media reporter, is the child of Indian immigrants. Imagine if we had never let these families in (or kicked their children out)?

And yet the future is still uncertain for these young undocumented people.

Meanwhile, our country is becoming increasingly hostile. American citizens are harassed as rumors circulate about people rounded up at their work and homes. My friend’s American family carries identification because, despite being citizens, their ethnic appearance has caused them to be questioned. Their children are directed to come straight home after school. People are scared.

This summer my husband and I decided to go to Canada for our annual birthday bike trip. We were driving in New York along the St. Lawrence river when we came to a roadblock.

A heavily armed man in army fatigues stepped up to our truck. Another armed man, pulled by a lunging German Shepherd, walked around the back and peered into our truck bed. Although we had nothing to hide or fear (we were American citizens in America, after all), I felt my heart quicken.

“What is your relationship?” the man who approached our vehicle asked with a smile.

“We’re married,” Paul and I answered in unison.

“Are you American citizens?” he asked.

“Yes,” we both answered together.

He looked through the window into the back seat of the truck which was piled high with our biking gear.

“Born and raised?” he asked.

“Yes,” I answered quickly.

“No,” said Paul.

I swallowed hard. Did it matter? A year ago I wouldn’t have thought so. But a year ago we probably wouldn’t have been asked.

“Are you naturalized?” he asked Paul. Paul nodded.

“Where and what year?” he asked, his smile fading.

“Hartford, Connecticut,” Paul answered. He stumbled on the year.

I held my breath and then blurted, “1977, right?” When Paul didn’t answer right away I continued, “You were eight, I think. What year was that?”

The pause was infinite.

Eventually, border patrol let us go. We were American citizens, after all.

As we drove away, though, I couldn’t help feeling uneasy about the whole exchange. Shouldn’t the interrogation have ended when we confirmed that we were American citizens? Since when did it matter if a person was “born and raised” here? And, what if we were not white? Might we have been detained longer? Asked to show proof? Had our vehicle searched?

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Birthday Bike Trip, Canada 2017

We can’t be lulled into passivity. Even if you are not married to an immigrant, even if your doctor is not a foreigner or foreign-trained, even if you don’t think you even know any immigrants because you live in a homogenous, non-diverse community – make no mistake. You will be impacted by anti-anything-that isn’t-American legislation.

Hopefully the impact will just be a nuisance, like difficulty traveling to another country (or even in your own if you aren’t white or have an accent). Maybe you’ll have to pay more for domestic fruits when there aren’t enough workers to pick it. Maybe you will have to wait a year to schedule a doctor’s appointment. It could be much, much worse though.

When we push away other cultures and and turn our backs on our neighbors we are not just hurting them, we are hurting ourselves. We are creating a deep wound in our society when we speak of building a wall or deporting young adults. When we allow the pardon of a sheriff renowned for racial profiling and violence we are sending a message to Americans (and to the rest of the world) that we accept bigotry and hatred.

When we react to each horrific act of terrorism by blaming an entire population (or dehumanize the perpetrator by labeling him “an animal”) we most definitely are not making America safer. We are furthering a division that, in small and terrifying pockets, may lead to extremism and actually cause terrorism.

I am a primary care doctor in a mostly white, rural community with relatives who arrived on the Mayflower. Yet the impact of anti-immigration and anti-anything-not-American on my own small life can’t be denied. I suspect if you look deep enough, you will discover that the impact on yours can’t be either.

I don’t want to live in a black and white world when I could live in rainbow.